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A 3-week-old male infant is brought to the emergency department because of a one-week history of increasing lethargy and persistent vomiting after feeding. The parents report that the color of the emesis is consistent with breast milk. The infant has not had any wet diapers during the past 8 hours. The infant weighs 8.8 lb (4 kg) and is afebrile. Physical examination shows a sunken fontanelle and dry mucous membranes, but is otherwise unremarkable. Results of laboratory studies shows a serum sodium level of 135 mEq/L, chloride of 90 mEq/L, potassium of 3.0 mEq/L, and bicarbonate of 34 mEq/L. An abdominal ultrasound is performed, demonstrating a pyloric channel length of 20 mm with a muscle wall thickness of 4 mm; no flow through the pyloric channel is apparent.

Following appropriate resuscitation and correction of electrolyte imbalances, laparoscopic pyloromyotomy is performed. After surgery, the infant has small amounts of nonbilious regurgitation while breastfeeding. The mother reports the emesis is not forceful as it had been before the operation. On follow-up examination, the infant does not appear to be any distress. The abdomen is soft and not distended; there is no tenderness to palpation.

Which of the following is the most appropriate next step in management?

a. Immediate initiation of antibiotics
b. Emergent surgery to determine whether any mucosal injury has taken place
c. Change of patient's feeding status to NPO for the next 48 hours
d. Reassurance that the vomiting will resolve with time
e. Upper gastrointestinal series
A 71-year-old man is evaluated for lightheadedness and weakness of the right arm since he awoke this morning. He reports trying to reach for his watch, "but my arm didn't respond to my brain's command." He dismissed the incident and went back to sleep. Two hours later, he awakened and was able to get out of bed without difficulty. At this time, his arm felt normal. He has no history of similar episodes. The patient, who has a 30-pack-year smoking history, has hypertension and hypercholesterolemia, and he sustained a myocardial infarction 6 years ago. He underwent coronary stent placement at that time. Current medications are aspirin, lisinopril, atorvastatin, and occasional ibuprofen for muscle pain.

On physical examination, the patient is not feeling lightheaded. temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 22/min, and blood pressure is 140/76 mm Hg. No bruits are heard. Muscle strength is 4 bilaterally. Neurological examination reveals no evidence of motor or sensory deficits.

A -Which of the following is the most likely diagnosis?
a. Intracranial cerebral aneurysm
b. Transient ischemic attack
c. Hemorrhagic stroke
d. Intracranial brain tumor
e. Ischemic stroke

B- Which of the following is the best next step in management?
a. Echocardiogram
b. Magnetic resonance imaging (MRI) of the brain
c. Admission for observation and anticoagulant therapy
d. Carotid ultrasound
e. Magnetic resonance angiography (MRA) of the neck

C- Which of the following guidelines will be most helpful for management of this condition?
a. North American Symptomatic Carotid Endarterectomy Trial (NASCET)
b. Carotid Revascularization Endarterectomy vs Stent Trial (CREST)
c. European Carotid Surgery Trial (ECST)
d. Asymptomatic Carotid Atherosclerosis Study (ACAS)
e. Asymptomatic Carotid Surgery Trail (ACST)